From perineal wound failure modes to a standardized care bundle in single-port robot-assisted transperineal radical prostatectomy: a before–after quality-improvement study

Background: Single-port robot-assisted transperineal radical prostatectomy (SP-RARP) may facilitate early continence recovery and can be considered for selected patients with obesity or prior abdominal surgery. However, our initial institutional cohort showed a clinically important rate of surgical site infection (SSI). Methods: This single-center before–after quality-improvement study compared a historical cohort of 60 patients who underwent SP-RARP with an implementation cohort of 35 patients managed using a standardized perineal incision care bundle. Potential SSI-related failure modes were identified from the historical cohort, and the perineal wound-care bundle was developed accordingly. The primary outcome was 30-day SSI; secondary outcomes included wound-culture positivity, antimicrobial escalation, readmission, time to wound dryness, time to drainage removal, time to urinary catheter removal, length of hospital stay, duration of postoperative fasting, total medical costs, incisional pain, allergic reactions, and perineal skin blistering. Results: In the historical cohort, SSI was associated with omitted perineal cleansing, lack of enhanced bowel preparation, residual hair, more perineal sutures, and prolonged strip-drain retention (all p < 0.05). Bundle implementation reduced SSI (p = 0.025), positive wound cultures, and mean medical costs, but was accompanied by slightly higher incisional pain and minor local skin reactions. Conclusions: Based on our exploratory study, a standardized perineal incision care bundle was associated with lower SSI, faster recovery, and reduced resource use after SP-RARP, while increased pain and local skin reactions were observed.

Prostate cancer; Single-port robotic surgery; Transperineal prostatectomy; Surgical-site infection; Quality improvement

[1] Yu C, Xu L, Ye L, Zheng Q, Hu H, Ni K, et al. Single-port robot-assisted perineal radical prostatectomy with the da Vinci XI system: initial experience and learning curve using the cumulative sum method. World Journal of Surgical Oncology. 2023; 21: 46.

[2] Leung AC, Melman A. Radical perineal prostatectomy: a more optimal treatment approach than laparoscopic radical prostatectomy in obese patients? Reviews in Urology. 2005; 7: 48–52.

[3] Tugcu V, Simsek A, Yigitbasi I, Yenice MG, Sahin S, Tasci AI. Robot-assisted perineal radical prostatectomy in a post-kidney transplant recipient. Journal of Endourology Case Reports. 2018; 4: 21–24.

[4] Ficarra V, Romito I, Sorce G, Maravigna D, De Stefano A, Mottrie A, et al. Comparison of single- and multiport robot-assisted approaches in prostate and renal surgery: a systematic review and meta-analysis. European Urology. 2025; 88: 589–613.

[5] Chang Y, Xu W, Lu X, Zhou Y, Ji M, Xiao YT, et al. Robotic perineal radical prostatectomy: initial experience with the da Vinci Si robotic system. Urologia Internationalis. 2020; 104: 710–715.

[6] Kaouk JH, Akca O, Zargar H, Caputo P, Ramirez D, Andrade H, et al. Descriptive technique and initial results for robotic radical perineal prostatectomy. Urology. 2016; 94: 129–138.

[7] Xu L, Yu C, An W, Zhu S, Hu H, Ni K, et al. Application of transperineal robot-assisted laparoendoscopic single-site radical prostatectomy. Chinese Journal of Urology. 2024; 45: 598–602. (In Chinese)

[8] Sharma RK, Parashar A. The management of perineal wounds. Indian Journal of Plastic Surgery. 2012; 45: 352–363.

[9] Meyer J, Roos E, Abbassi Z, Toso C, Ris F, Buchs NC. The role of perineal application of prophylactic negative-pressure wound therapy for prevention of wound-related complications after abdomino-perineal resection: a systematic review. International Journal of Colorectal Disease. 2021; 36: 19–26.

[10] Wiatrek RL, Thomas JS, Papaconstantinou HT. Perineal wound complications after abdominoperineal resection. Clinics in Colon and Rectal Surgery. 2008; 21: 76–85.

[11] Cahill C, Fowler A, Williams LJ. The application of incisional negative pressure wound therapy for perineal wounds: a systematic review. International Wound Journal. 2018; 15: 740–748.

[12] Kaneko T, Funahashi K, Ushigome M, Kagami S, Goto M, Koda T, et al. Incisional negative pressure wound therapy to reduce perineal wound infection after abdominoperineal resection. International Wound Journal. 2021; 18: 103–111.

[13] Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al.; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surgery. 2017; 152: 784–791. Erratum in: JAMA Surgery. 2017; 152: 803.

[14] World Health Organization. Global guidelines for the prevention of surgical site infection. World Health Organization: Geneva. 2016.

[15] Falkensammer E, Erenler E, Johansen TEB, Tzelves L, Schneidewind L, Yuan Y, et al. Antimicrobial prophylaxis in robot-assisted laparoscopic radical prostatectomy: a systematic review. Antibiotics. 2023; 12: 1744.

[16] Mitsui M, Sadahira T, Nagasaki N, Maruyama Y, Sekito T, Iwata T, et al. Postoperative infections after robotic-assisted radical prostatectomy in a single large institution: effect of type and duration of prophylactic antibiotic administration. International Journal of Urology. 2025; 32: 258–263.

[17] Yang Q, Yang H, Long W, Zuo S, Zhu D, Guo Q. Rapid cognitive assessment: accuracy and discriminant validity of Mini-Cog and process-based Clock Drawing Test. Journal of Alzheimer’s Disease. 2025; 104: 200–208.

[18] Wolfhagen N, Boldingh QJJ, Boermeester MA, de Jonge SW. Perioperative care bundles for the prevention of surgical-site infections: meta-analysis. British Journal of Surgery. 2022; 109: 933–942.

[19] Christian CK, Kwaan MR, Betensky RA, Breen EM, Zinner MJ, Bleday R. Risk factors for perineal wound complications following abdominoperineal resection. Diseases of the Colon & Rectum. 2005; 48: 43–48.

[20] Groenen H, Bontekoning N, Jalalzadeh H, Buis DR, Dreissen YEM, Goosen JHM, et al. Incisional wound irrigation for the prevention of surgical site infection: a systematic review and network meta-analysis. JAMA Surgery. 2024; 159: 792–800.

[21] Hong JC, Chen JS, Jiang ZJ, Chen ZC, Ruan N, Yao XP. Microbiota in adult perianal abscess revealed by metagenomic next-generation sequencing. Microbiology Spectrum. 2024; 12: e0347423.

[22] Badia JM, Casey AL, Petrosillo N, Hudson PM, Mitchell SA, Crosby C. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. Journal of Hospital Infection. 2017; 96: 1–15.

[23] Cheng CE, Kroshinsky D. Iatrogenic skin injury in hospitalized patients. Clinics in Dermatology. 2011; 29: 622–632.